Initial Experience with Laparoscopic Loop Duodenojejunal Bypass with Sleeve Gastrectomy in Korean Obese Patients

Laparoscopic loop duodenojejunal bypass with sleeve gastrectomy (LDJB-SG) has theoretical advantages compared with laparoscopic Roux-en-Y gastric bypass. We performed 7 cases of LDJBSG from May 2019 to September 2019. All procedures were successfully completed by laparoscopy. The mean operative time was 282.9 (210~335) minutes and the mean estimated blood loss was 82.9 (20~150) ml. There was no intraoperative complications, however, there was 1 case of postoperative anastomotic leakage. The average length of postoperative hospital stay was 5.3 (3~12) days. The mean body weight at baseline was 117.1 (88.4~151.1) kg, and was decreased to 90.4 (69.4~130.9) kg at postoperative 3 month. The mean of HbA1c at baseline was 7.6 (5.5~9.4) %, and was decreased to 5.3 (4.8~5.6) % at postoperative 3 month. Although LDJB-SG is a technically demanding procedure, it can be a feasible and safe procedure if the learning curve can be overcame.

Metabolic Outcomes of Surgery for Non-Obese Type 2 Diabetes

The most plausible contributing factor to non-obese type 2 diabetes may be imbalanced incretin release from the intestinal epithelium in response to nutrients. Rerouting intestinal continuity through bypass surgery to modulate incretin release is therefore a reasonable treatment. We believe that a major determinant of metabolic outcomes is entire duodenal exclusion without leaving any duodenal epithelium and exclusion of sufficient length of jejunum. More importantly, the procedure should be implemented with safety and without sequelae. To achieve this, we invented a novel procedure with acceptable surgical safety and excellent and durable metabolic outcomes. Post-surgical intestinal adaptation should be considered to achieve successful outcomes.

Mini-Gastric Bypass to Control Morbid Obesity and Diabetes Mellitus: What Radiologists Need to Know

Laparoscopic mini-gastric bypass surgery is a safe and simple surgical intervention for treating morbid obesity and diabetes mellitus and is now being performed more frequently. Radiologists must be critical in their postoperative evaluation of these patients. In this pictorial review, we explain and illustrate the surgical technique, normal postoperative anatomy, and associated complications as seen on imaging examinations, including fluoroscopy and computed tomography.

The Learning Curve of the Beginner Surgeon with Supervisor for Laparoscopic Totally Extraperitoneal Repair

PURPOSE: Despite acceptance of laparoscopic totally extraperitoneal (TEP) repair for repair of inguinal hernia, it is still considered to require a prolonged learning curve. We hypothesized that there would be differences in the learning curve for laparoscopic TEP repair among beginner surgeons with or without a supervisor. The current study was conducted to observe the learning curve for laparoscopic TEP repair performed by a surgeon without a supervisor. METHODS: A retrospective analysis of the consecutive 143 patients was conducted to document patients' demographics, hernia types, operative time, and operative outcomes after the operation. Patients were divided into 7 consecutive groups, each comprising 20 patients. RESULTS: The mean age of the study population was 52.5 years (+/- 18.9 SD), ranging from 16 to 89 years. The learning curve of this technique was almost horizontal throughout the time course. The mean operative time was quite stable among each group. Comparison of the mean operation time and the length of hospital stay among each group did not show significant differences. There was one recurrence in group V. CONCLUSION: The learning curve for laparoscopic TEP repair is not that prolonged if there is an experienced specialized supervisor and opportunities to observe the entire procedure performed by the supervisor are available. It is not the laparoscopic instrument skills but the way the procedure is performed that is important for successful outcomes.

2014 Clinical Practice Guidelines for Overweight and Obesity in Korea

The dramatic increase in the prevalence of obesity and its accompanying comorbidities are major health concerns in Korea. Obesity is defined as a body mass index > or =25 kg/m2 in Korea. Current estimates are that 32.8% of adults are obese: 36.1% of men and 29.7% of women. The prevalence of being overweight and obese in national surveys is increasing steadily. Early detection and the proper management of obesity are urgently needed. Weight loss of 5% to 10% is the standard goal. In obese patients, control of cardiovascular risk factors deserves the same emphasis as weight-loss therapy. Since obesity is multifactorial, proper care of obesity requires a coordinated multidisciplinary treatment team, as a single intervention is unlikely to modify the incidence or natural history of obesity.

Is transverse abdominis plane block effective following local anesthetic infiltration in laparoscopic totally extraperitoneal hernia repair? / 대한마취과학회지

BACKGROUND: Transverse abdominis plane (TAP) block can be recommended as a multimodal method to reduce postoperative pain in laparoscopic abdominal surgery. However, it is unclear whether TAP block following local anesthetic infiltration is effective. We planned this study to evaluate the effectiveness of the latter technique in laparoscopic totally extraperitoneal hernia repair (TEP). METHODS: We randomly divided patients into two groups: the control group (n = 37) and TAP group (n = 37). Following the induction of general anesthesia, as a preemptive method, all of the patients were subjected to local anesthetic infiltration at the trocar sites, and the TAP group was subjected to ultrasound-guided bilateral TAP block with 30 ml of 0.375% ropivacaine in addition before TEP. Pain was assessed in the recovery room and post-surgery at 4, 8, and 24 h. Additionally, during the postoperative 24 h, the total injected dose of analgesics and incidence of nausea were recorded. RESULTS:: On arrival in the recovery room, the pain score of the TAP group (4.33 +/- 1.83) was found to be significantly lower than that of the control group (5.73 +/- 2.04). However, the pain score was not significantly different between the TAP group and control group at 4, 8, and 24 h post-surgery. The total amounts of analgesics used in the TAP group were significantly less than in the control group. No significant difference was found in the incidence of nausea between the two groups. CONCLUSIONS: TAP block following local infiltration had a clinical advantage only in the recovery room.

Laparoscopic Inguinal Hernia Repair by Intraperitoneal Onlay Mesh (IPOM) Technique in Specific Cases as an Alternative Method

PURPOSE: Despite advancements in surgery, laparoscopic totally extraperitoneal (TEP) repair for inguinal hernia in patients with previous lower abdominal surgeries has been a burden to surgeons. This study was conducted in order to assess the feasibility of laparoscopic intraperitoneal onlay m esh (IPOM) hernia repair as an alternative method for these cases. METHODS: From May 2006 to November 2010, 48 IPOM repairs were performed in 43 patients. All medical records were reviewed retrospectively. RESULTS: Mean age of patients was 61 years old and male to female ratio was 37:6. Five were direct and 43 were indirect hernias. There were 15 recurrent inguinal hernias after either open or laparoscopic hernia repair, and five of 15 were recurrent cases more than two times. Mean operative time was 44.5 minutes, and mean postoperative hospital stay was 1.41 days. There were two cases of postoperative swelling at the groin area and two patients complained of pain that required oral pain-killers during out-patient follow-ups. Recurrence developed in one case. CONCLUSION: Even though laparoscopic IPOM repair is not a preferred m ethod for inguinal hernia, it can be applied as an alternative method in specific cases involving difficulties in approaching the usual plane of repair.

Comparison of the outcomes between laparoscopic totally extraperitoneal repair and prolene hernia system for inguinal hernia; review of one surgeon's experience / 대한외과학회지

PURPOSE: To compare the outcomes between laparoscopic total extraperitoneal (TEP) repair and prolene hernia system (PHS) repair for inguinal hernia. METHODS: A retrospective analysis of 237 patients scheduled for laparoscopic TEP or PHS repair of groin hernia from 2005 to 2009 was performed. RESULTS: The mean age was 52.3 years in TEP group and 55.7 years in PHS group. Of 119 TEP cases, 98 were indirect inguinal hernia, 15 direct type, 5 femoral hernia and 1 complex hernia; Of 118 PHS cases, 100 indirect, 18 direct type. All in TEP group were performed under general anesthesia and 64% of PHS group were performed under spinal or epidural anesthesia. Preoperatively, 10 cases of recurrent inguinal hernia were involved in our study (4 in TEP, 6 in PHS group). The mean operative time was similar in both groups (74.8 in TEP, 71.2 in PHS group), however mean hospital stay (1.6 days in TEP, 3.2 days in PHS group, P = 0.018) and mean usage of analgesics (0.54 times in TEP, 2.03 times in PHS group, P < 0.01), complications (36 cases in TEP, 6 cases in PHS group, P < 0.01) showed statistical differences. There is only 1 case of postoperative recurrence inguinal hernia in PHS group but it has no statistical significance (P = 0.314). CONCLUSION: Compared to PHS repair, laparoscopic TEP repair has some advantages; shorter hospital stay, less frequent need of analgesics; as well as more postoperative complications such as hematoma, seroma, scrotal swelling.

Current Status of Laparoscopic Liver Resection in Korea

Since laparoscopic liver resection was first introduced in 2001, Korean surgeons have chosen a laparoscopic procedure as one of the treatment options for benign or malignant liver disease. We distributed and analyzed a nationwide questionnaire to members of the Korean Laparoscopic Liver Surgery Study Group (KLLSG) in order to evaluate the current status of laparoscopic liver resection in Korea. Questionnaires were sent to 24 centers of KLLSG. The questionnaire consisted of operative procedure, histological diagnosis of liver lesions, indications for resection, causes of conversion to open surgery, and postoperative outcomes. A laparoscopic liver resection was performed in 416 patients from 2001 to 2008. Of 416 patients, 59.6% had malignant tumors, and 40.4% had benign diseases. A total laparoscopic approach was performed in 88.7%. Anatomical laparoscopic liver resection was more commonly performed than non-anatomical resection (59.9% vs 40.1%). The anatomical laparoscopic liver resection procedures consisted of a left lateral sectionectomy (29.3%), left hemihepatectomy (19.2%), right hemihepatectomy (6%), right posterior sectionectomy (4.3%), central bisectionectomy (0.5%), and caudate lobectomy (0.5%). Laparoscopy-related serious complications occurred in 12 (2.8%) patients. The present study findings provide data in terms of indication, type and method of liver resection, and current status of laparoscopic liver resection in Korea.

Simultaneous Laparoscopic Band Removal and Sleeve Gastrectomy: Case Report and Review of Literature

More attention has been paid to bariatric surgery due to an increase in the obese population in Korea. Laparoscopic adjustable gastric banding (LAGB) is the most popular procedure for weight-loss but the complication rate may increase with time. Revision surgery is needed if there are complications or the weight is regained after LAGB, and a laparoscopic sleeve gastrectomy could be performed in the case of band failure. Successful band removal and sleeve gastrectomy wereperformed simultaneously without complications.

Is the Spinous Process of T7 Usually at the Same Level as the Inferior Tips of the Scapulae?

OBJECTIVE: Appropriate placement of thoracic epidural catheter provides an adequate postoperative analgesia in chest and upper abdominal surgery. Usually, when thoracic epidural puncture is performed, both scapular lower tips and the thoracic (T)7 spinous process is assumed to be at the same horizontal level. The aim of this study is to identify the thoracic epidural puncture in the sitting position, with the neck flexed and arms crossed, may change the relationship between the thoracic vertebrae and the scapular lower tips. METHODS: One hundred patients with postoperative patient controlled epidural analgesia using thoracic epidural catheters were enrolled. It is presumed that the both scapular lower tips and T7 spinous process is at the equal level when performing thoracic epidural puncture. The actual insertion level of the Tuohy needle was examined by radiography when the patient was in the sitting position. RESULTS: Out of 100 patients, there were 62% that were in the same level as the scapular lower tips and T7 spinous process. However, 1% of the patients leveled at T4, 1% at T5, 25% at T6, 18% at T8, and 1% at T9. CONCLUSION: When performing the thoracic epidural puncture under the sitting position, the relationship of the T7 and the scapular lower tips may change. The change of position of scapular lower tips varied among T6.82+/-0.70. Therefore, to be precise, it is advised to utilize C-arm guide when epidural puncture is carried out.

Is routine nasogastric tube insertion necessary in pancreaticoduodenectomy? / 대한외과학회지

PURPOSE: The necessity of nasogastric decompression after abdominal surgical procedures has been increasingly questioned for several years. Traditionally, nasogastric decompression is a mandatory procedure after classical pancreaticoduodenectomy (PD); however, we still do not know whether or not it is necessary for PD. The present study was designed to assess the clinical benefit of nasogastric decompression after PD. METHODS: Between July 2004 and May 2007, 41 consecutive patients who underwent PD were enrolled in this study. Eighteen patients were enrolled in the nasogastric tube (NGT) group and 23 patients were enrolled in the no NGT group. RESULTS: There were no differences in the demographics, pathology, co-morbid medical conditions, and pre-operative laboratory values between the two groups. In addition, the passage of flatus (P = 0.963) and starting time of oral intake (P = 0.951) were similar in both groups. In the NGT group, 61% of the patients complained of discomfort related to the NGT. Pleural effusions were frequent in the NGT group (P = 0.037); however, other post-operative complications, such as wound dehiscence and anastomotic leakage, occurred similarly in both groups. There was one case of NGT re-insertion in the NGT group. CONCLUSION: Routine nasogastric decompression in patients undergoing PD is not mandatory because it has no clinical advantages and increases patient discomfort.

The surgical treatment for type 2 diabetes mellitus

Type 2 diabetes mellitus (T2DM) has become an epidemic. Compared to Western countries, Asian T2DM occurs in patients with a lower body mass index, due to central obesity and decreased pancreatic beta-cell function. The efficacy of surgical treatment such as sleeve gastrectomy, adjustable gastric banding, and gastric bypass in obese patients with T2DM has been demonstrated by numerous studies from Western countries. However, current evidence on surgical treatment for non-morbidly obese diabetic patients is lacking. Recently, several preliminary studies demonstrated the remission of hyperglycemia in non-obese T2DM patients by surgical bypass. One possible hypothesis is the foregut theory an inactivation of the anti-incretin system through the exclusion of the foregut from ingested food, and the other is the hindgut theory, in which rapid hindgut exposure prompts the delivery of undigested food to the terminal ileum and promotes the activation of incretin system such as glucagon-like peptide-1 The following teaching points and direction of future study are recommended: understanding the mechanism of diabetic remission through surgical procedure, defining the surgical indications for T2DM, predicting the possible complications and disadvantages of surgical treatment, and understanding the peculiarity of each surgical procedure. The remission of hyperglycemia in non-obese T2DM patients could possibly be achieved by surgical intervention. Although long-term follow-up data and verification of its exact mechanisms are required, early operative outcomes were satisfactory in terms of glycemic control and the safety of the procedure.

Laparoscopic total extraperitoneal repair for incarcerated inguinal hernia / 대한외과학회지

PURPOSE: We wanted to measure and compare the patient demographics and perioperative outcomes between patients with incarcerated and patients with non-incarcerated inguinal hernia. METHODS: We conducted a retrospective analysis of 945 patients who were scheduled for laparoscopic total extraperitoreal (TEP) repair of inguinal hernia from May 2002 to May 2010. There were 66 patients who had incarcerated hernia and 879 patients who had non-incarcerated hernia. RESULTS: The mean age was younger in the incarcerated hernia group than in the non-incarcerated hernia group (41.67 vs. 48.50 years, P < 0.01), and all the incarcerated inguinal hernias patients were male. Most of the incarcerated hernias (63 out of 66 cases, 95%) were indirect hernias. The mean hospital stay showed no difference between the two groups (1.03 vs. 0.93 days, P = 0.142) but the operation time was longer for the incarcerated group than that for the non-incarcerated group (33.36 vs. 24.59 minutes, P < 0.01). Postoperative swelling (including seroma) was more frequent in the incarcerated group (14 out of 66 cases, 21%, P < 0.01), but postoperative pain was similar in both groups (3.0 vs. 8.9%, P = 0.095). There was one recurrence in the non-incarcerated group, but this had no statistical significance. CONCLUSION: Laparoscopic TEP repair for the patients with chronic incarcerated inguinal hernias was safe and feasible. However, a well-designed study is needed to confirm if it is suitable for acute incarcerated inguinal hernias.

Laparoscopic Appendectomy for Complicated Appendicitis: Retrospective Analysis for the Surgical Outcomes and Cost-effectiveness / 대한내시경복강경외과학회지

PURPOSE: Due to coverage by the nationwide medical insurance system for laparoscopic appendectomy, the laparoscopic approach for complicated appendicitis has been widely performed in Korea. The aim of this study is to evaluate the surgical outcomes and cost effectiveness of laparoscopic appendectomy for complicated appendicitis. METHODS: This study included 33 patients who underwent the laparoscopic approach (LA) and 26 patients who underwent the open approach (OA) for the complicated appendicitis between March, 2005 and February, 2010. We compared the outcomes of the length of stay, the complications and the costs. RESULTS: The hospital stay was 4.9 days for LA and 6.2 days for OA. (p>0.05) The overall complication rates were 21% (7/33) for LA and 27% (7/26) for OA. (p>0.05) All the complications were managed conservatively and there was no mortality in either group. The total cost and the patient's charge was Won 3,390,421 and Won 1,574,093 for LA and Won 3,260,523 and Won 1,493,510 for OA, respectively (p>0.05). CONCLUSION: The laparoscopic approach is safe, efficacious and cost effective. It should be the initial procedure of choice for most cases of complicated appendicitis.

Determination of Malignant and Invasive Predictors in Branch Duct Type Intraductal Papillary Mucinous Neoplasms of the Pancreas: A Suggested Scoring Formula

Prediction of malignancy or invasiveness of branch duct type intraductal papillary mucinous neoplasm (Br-IPMN) is difficult, and proper treatment strategy has not been well established. The authors investigated the characteristics of Br-IPMN and explored its malignancy or invasiveness predicting factors to suggest a scoring formula for predicting pathologic results. From 1994 to 2008, 237 patients who were diagnosed as Br-IPMN at 11 tertiary referral centers in Korea were retrospectively reviewed. The patients' mean age was 63.1 +/- 9.2 yr. One hundred ninty-eight (83.5%) patients had nonmalignant IPMN (81 adenoma, 117 borderline atypia), and 39 (16.5%) had malignant IPMN (13 carcinoma in situ, 26 invasive carcinoma). Cyst size and mural nodule were malignancy determining factors by multivariate analysis. Elevated CEA, cyst size and mural nodule were factors determining invasiveness by multivariate analysis. Using the regression coefficient for significant predictors on multivariate analysis, we constructed a malignancy-predicting scoring formula: 22.4 (mural nodule [0 or 1]) + 0.5 (cyst size [mm]). In invasive IPMN, the formula was expressed as invasiveness-predicting score = 36.6 (mural nodule [0 or 1]) + 32.2 (elevated serum CEA [0 or 1]) + 0.6 (cyst size [mm]). Here we present a scoring formula for prediction of malignancy or invasiveness of Br-IPMN which can be used to determine a proper treatment strategy.

Gallbladder pseudolithiasis caused by ceftriaxone in young adult / 대한외과학회지

Ceftriaxone is a commonly used antibiotic due to some of its advantages. Reversible gallbladder (GB) sludge or stone has been reported after ceftriaxone therapy. Most of these patients have no symptom, but the GB sludge or stone can sometimes cause cholecystitis. We experienced two patients who had newly developed GB stones after ceftriaxone therapy for diverticulitis and pneumonia, and this resolved spontaneously 1 month after discontinuation of the drug. Awareness of this complication could help to prevent unnecessary cholecystectomy.

Initial Experience of Laparoscopic Sleeve Gastrectomy in Morbidly Obese Patients

PURPOSE: Laparoscopic sleeve gastrectomy (LSG) is rapidly gaining ground as one of the surgical procedures in bariatric surgery with emerging long-term follow-up data. The aim of the present study was to report our initial experience of LSG in morbidly obese patients. METHODS: Sixty-four consecutive patients underwent LSG from April 2009 to July 2010 at our bariatric surgery center. Patients eligible for LSG were those with a body mass index (BMI) of >37 kg/m2, and >32 kg/m2 with co-morbidities. LSG was performed using 5 trocars and endo-staplers with guidance of 34 Fr bougie. Perioperative management was standardized. The clinical data were prospectively collected and retrospectively analyzed. RESULTS: Among 64 patients, 19 were male and 45 were female, mean age was 35 years (range 20~57), mean preoperative BMI was 38.8 kg/m2 (range 32~57), and mean preoperative body weight was 108 kg (range 75~164). Mean operative time was 118 minutes (range 65~340) and mean length of hospital stay was 3.4 days (range 1~82). Staple line leak occurred in 1 patient, kinking of the gastric tube occurred in 2 patients. There was no open conversion and no postoperative mortality. After 170 days of follow-up, 24.4 kg of body weight loss and 52.7% of excess weight loss (%EWL), on average, was noted. CONCLUSION: Though long-term follow-up is needed, our early operative outcome was satisfactory in terms of %EWL and safety of the procedure. LSG was a safe and effective treatment strategy for morbidly obese patients.

The Feasibility of Laparoscopic Total Extraperitoneal (TEP) Herniorrhaphy after Previous Lower Abdominal Surgery

PURPOSE: We retrospectively reviewed the medical records to estimate the feasibility and surgical outcome of laparoscopic herniorrhaphies in patients with previous lower abdominal surgery. METHODS: Between December 2000 and December 2008, a total of 1,101 cases of laparoscopic herniorrhaphies were performed in 974 patients, among them 47 cases (4.27%) of laparoscopic herniorrhaphy in 40 patients who had undergone previous lower abdominal surgery were enrolled to this study. RESULTS: Most patients (23 of 24) who had a history of appendectomy successfully underwent laparoscopic totally extraperitoneal (TEP) repair. Six patients who had history of a prostatectomy and 2 patients with a Pfannenstiel incision underwent an intraperitoneal only mesh (IPOM) repair after a failed TEP repair. Five patients had lower midline incisions due to panperitonitis, among them TEP repairs were performed in 3 patients and IPOM was performed after failed TEP repairs in 2 patients who had undergone surgery due to trauma-induced rupture of the bladder. CONCLUSION: Laparoscopic TEP hernia repair could be possible and reasonable in patients after an appendectomy; however, it is difficult in patients with previous pelvic surgeries. Additional studies are needed to determine whether or not laparoscopic TEP repair for inguinal hernias is feasible in patients who have undergone other general surgical procedures.

The Effectiveness of Laparoscopic Ventral Hernia Repair with Transfascial Fixation / 대한내시경복강경외과학회지

PURPOSE: The introduction of a mesh to ventral herniorrhaphy ensures abdominal wall strength without tension, and this procedure has shown a decreased recurrence rate, a shorter hospital stay and less use of analgesics. However, the extensive tissue dissection required for mesh placement leads to increased postoperative complications. Yet with the development of laparoscopic ventral herniorrhaphy, we expect earlier recovery, fewer complications and decreased recurrence rates. This study was done to compare the outcomes after open and laparoscopic ventral herniorrhaphy with using mesh through a retrospective review. METHODS: The outcomes for 20 consecutive patients who underwent laparoscopic ventral herniorrhaphy were compared with those of 20 consecutive patients who underwent open herniorrhaphy. The laparoscopic repairs were performed using the intraperitoneal onlay mesh (IPOM) repair with transfascial fixation method in all the cases. RESULTS: The forty patients (24 women and 16 men) had a mean age of 57.48 years (range, 33~82). The mean follow-up time was 63.4 months. The mean surgery duration (67.4 min vs 142.3 min, respectively, p=0.003) and postoperative stay (4.7 vs 16.2 days, respectively, p<0.0001) were shorter for the laparoscopic group. The number of shots of analgesics during the first 3 days after surgery was 1.9 vs 2.4 shots, respectively (p=0.019). There were fewer complications (30%) and recurrences (5%) among the patients who underwent laparoscopic repair than those for the patients who underwent open repair (65% and 10 %, respectively). CONCLUSION: Those findings shows that laparoscopic ventral herniorrhaphy with transfascial fixation seems to be safe and effective and it showed a shorter operative time, fewer complications, a shorter hospital stay and less recurrence than did open ventral herniorrhaphy.